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Box 123 City, AL 12345 LOSS PREVENTION PROGRAM ~ NEAR MISS REPORT Operators Name: ________________________________________________ Job Title: ________________________________________ Incident Date: __________________________ Time: ___________________ (AM) (PM) Report Time: _____________________________ Is Employee Regular Operator? ___________ Yes ___________ No License Current? ___________ Yes ___________ No Make Of Vehicle Involved: __________________________________________ Model Year: ______________________________________ Vehicle Number: ___________________ License Tag Number: _________________ Date Last Vehicle Inspection: _________________ Police Notified? ___________ Yes ___________ No Ambulance/Fire Called? ___________ Yes ___________ No Incident Location ___________________________________________________________________________________________________ Number Of Employees That May Have Been Injured? ______________________________________________________________________ Description Of Incident: _____________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ In Your Opinion, What Can Be Done To Prevent This Incident From Recurring ?_________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Action Taken Or To Be Taken To Prevent Recurrence: _____________________________________________________________________ _________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________ Operator Signature: ________________________________________ Foreman Signature: ______________________________________ Review By Director of Public Works:______________________________________________________________________________________ Safety Coordinator Signature: ______________________________________ Date Of Review: _______________ File Reference: _______ ATTACH ADDITIONAL SHEETS AS NECESSARY     DEPARTMENT OF PUBLIC WORKS Insert Logo Here #23]bo'()*,-/0235OPQRSghiȽе㩞Ѕwokokokokgck_kwh[hhHNhb jhb UhHNCJ OJQJ^JaJ hX'hHNCJaJhHNCJOJQJ^JaJhX'hHNCJ aJ hX'hHN>*CJaJhHNCJaJhX'hHNCJaJh`CJaJ hX'hHNh`h`CJaJhX'hHNCJaJ"jh[CJUaJmHnHu%3pW X R S N O 8 9 ( ) $a$ hiYZ?@%&~()+,./1245PQRSTUfg$a$gd[dp$^a$$a$$a$ghi$a$;0P:p[/ =!"#$% Dps2&6FVfv2(&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv&6FVfv8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH L`L Normal1$7$8$H$CJ_HaJmH sH tH DA D Default Paragraph FontRiR  Table Normal4 l4a (k (No List <& < Footnote Reference44 X'Header  !4 4 X'Footer  !PK![Content_Types].xmlN0EH-J@%ǎǢ|ș$زULTB l,3;rØJB+$G]7O٭VvnB`2ǃ,!"E3p#9GQd; H xuv 0F[,F᚜K sO'3w #vfSVbsؠyX p5veuw 1z@ l,i!b I jZ2|9L$Z15xl.(zm${d:\@'23œln$^-@^i?D&|#td!6lġB"&63yy@t!HjpU*yeXry3~{s:FXI O5Y[Y!}S˪.7bd|n]671. tn/w/+[t6}PsںsL. 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